Provider Demographics
NPI:1295236792
Name:ESTUPINIAN, EDWAR JOSE FERNANDO
Entity type:Individual
Prefix:MR
First Name:EDWAR
Middle Name:JOSE FERNANDO
Last Name:ESTUPINIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 PACIFIC BLVD SE STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-7903
Mailing Address - Country:US
Mailing Address - Phone:541-286-5002
Mailing Address - Fax:541-246-8826
Practice Address - Street 1:2225 PACIFIC BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-7907
Practice Address - Country:US
Practice Address - Phone:541-286-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC6204101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health